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Home My WebLink AboutApplication and WC �y f ? , ��16 � . � C �}_, KU17 �► ► TOWN OF YARMOUTH BOARD OF HEALTH :, � � APPLICATION FOR LICENSE/PERMIT -2012 NOV O 4 Z O�� ...�. * Please complete form and attach all necessary documents by Decembe H�.�_,. Failure to do so will result in the return of your application pac e _;: ., ESTABLISHMENT NAME: �� ' �'f�� iN TAX ID: LOCATION ADDRESS: �'v� �� a�-b TEL.#: �n�'-.?9y-D 7�J,� MAII.ING ADDRESS: �.D,Bvx 79I.5��:�r� �,�ov�_ ry.� �l� OWNER NAME: ' CORPORATION NAME(IF APPLICABLE): ; MANAGER'S NAME: TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,a�s^required by State law. Please list the designated ----��v>�a"'rot�rfel on�l tt nh .z n� v r�f thn��.'��-tY7i�:_—: _ _, _. _ _-�- --_.�__- �vzca-_-�...� _..___ _.__.__.._ .. -..t'J -. - _- . . 1. �� lQ7l� ��`Z.� 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid � and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must ; provide new copies and maintain a file at your place of business. 1. �•✓`�"!�7P!h �7 �d7�R�b l� � 2, ' 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: � All food service establishments are required to have at least one full-time employee who is certified as a Food ; Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. ' Please attach copies of certification to this application. The Health Department will not use past years'records. ; You must provide new copies and maintain a file at your establishment. ' l. 2. i PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich . Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years'records. You must provide new copies and maintain a file at your place of business. ' 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOT'EL $55 _!NN $55 _ _�AIL:P $55 � J`J`JIMrviING PO^�L $8Cea.�� _LODGE $55 _T�_FRPARK $105 _WHIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ! _0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFIT $30 ' _>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 ' NAME CHANGE: $is AMOUNT DUE _ � S O• �J *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ' � � � ADMINISTRATION ` , Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance ar renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED� STATE WORKER'S COMPENSATION INSURANCE AFFTDAVIT MUST BE COMPLETED ANB SIGNED, OR CERT. OF INS(JI:AN��A'�T��CHED . OR , WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED i � I Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS ; i TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy i Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)days �, prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has been inspected , and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count �, by a State certif'ied lab, and submitted to the Health Department three (3) days prior to opening, and quarterly ', thereafter. I POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. I FOOD SERVICE ' SEASONAL FOOD SERVICE OPE1vING: I All food service establishments must be inspected by the Health Department prior to opening. Please contact the � Health Department to schedule the inspection three(3)days prior to opening. CATERING POLICY: � I Anyone who caters within the Town of Yarmouth must notify th� Yarmouth Health Department by filing the ' required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be ' obtauied at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, i Downloadable Forms. '� FROZEN DESSERTS: I Frozen desserts must be tested by a State certified lab priar to opening and monthly thereafter,with sample results ', submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen ', Dessert Permit until the above terms have been met. '� , OUTSIDE CAFES: Outside caf�s(�,e„ou�ds24r seatin�with waiter/waitress service),_must_have_�rior ap�roval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishtnent is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2011. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQU SITE PLAN. DATE: J/-3// SIGNATURE: �L,Lu PRINT NAME&TITLE: �,Nu?� �1 ,C�'�Y/�-A ��fS,. �vLL�� 1��'�/�.��irs .t�'�G Rev.10/25/11 r P , ' � The Commonwealth of Mwssachusetts Department of Industiria!AcciJents . > N�I Niw�sdw/11Mi , _ 600 �T'ashi�gton Street, f",'Floor " ti . : �oston,t1�as� 021 U : '- 3 ; ..# , Woii�ers'Compeesatios I�iseraace AfRdav'�it: � . . .- ' � , AnoNe�t i��tl��• Ple�b`e P.�IN'l'�htblt, �,= r � `' * - name: �1-�/�L l'�C� /'T-�/��e/�T�.,/�S�«�:��X . : ; .,. - address_-- r.�_� �� / ! _.— /�� #7��J�i ��1 . �D�A ciry <J�11��,� �f/��h�l�/� state: �� zin:�ii �i�s� phont# .��.��1�-�7�,�. work site tceation ffull addressl: ❑ I am a homeowner performing all wark myself. ❑ I am a sole proprietor and have no one working in any capacity. ❑ I am an employer providing workers'compensation f�my employees wodcing on this jc�l/ ._ _ - --- ----- � - ---- -- _-_-- - - com �ame- ' address• � 5 �r: ' �. �a � � �� ❑ I am a sole proprietor,geoeral eo�tractor,or homeo �a�uc)and have hired the contractors listed below wb have u the following woiicers'compensation polices: "P , .. . �� ; ; , _ _ _ � , , , addras• ' ci V N: .t, , , , ; i��ra�ee eo. i� w�m�v��ame• � � ad�ress: ; cttv: oro�e*• _ - - - - - --- _ _ _ _ _ _ __ ies4a�ee eo. _ _ _ �licy!� A11�elt�f'irt�frenlirf ° - . FaY�te r see�re a�era�e as reqtired�rdQ 3eetlN 2SA�[MGL 1S2 cu le�d a tre h�p��tui�Yd pn�Nles�f s me�p b ll,SN�N aid/w oee ye�n'ImprNo�aeet a�wd as cM peealtla la t6e 6rr o[a 3TOr WORK ORDBR ud N me d S1M.YS a day aSaMt a�e. I nden�ud t6rt a espy at thb�ta�emeot my be fKwarded b the O�ce a[laratl�Was ot t6e DIA hr e�rerase rerledtlN. /do berrby certFJy rader pa awd pee�lfiat olPerjwry tAr�t tlYt Jwfonw�tloe provlded oboae Ja d�rt awd conYct s�� a�s n�n �f 3�J1 Print narne /��if{ � ' C�iY�r� Phone# .�D�;��7�•��, ef5cfal ox enty do oet write�thb"area te 6e completed by eky or 6�ws o�cLl ' eity or town: permiHHeeme N �Bnidtes Deparbmeet . , _ r� ' > QL{eee�8oard . ❑chedt Klmsediale respeme b reqdnd, . �Sdeetues's Ofeee , . _ , . . QHea1tY DepaTti�nt ' rnatact petsoe: p6He N; Q(khe l�..ca s�.mao> . > _. ��__��_—- _